LAWYERS PROFESSIONAL LIABILITY SF NEW BUSINESS APPLICATION FOR LAW FIRMS WITH 9 OR LESS LAWYERS

Transcription

1 20 South Clark Street O Suite F Chicago, Illinois isbamutual.com LAWYERS PROFESSIONAL LIABILITY SF NEW BUSINESS APPLICATION FOR LAW FIRMS WITH 9 OR LESS LAWYERS NOTICE: THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. TO BE COVERED, A CLAIM MUST BE BOTH FIRST MADE AGAINST AN INSURED AND REPORTED TO THE COMPANY IN WRITING DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, IF ANY, AND IS SUBJECT TO THE POLICY PROVISIONS. This Application is to be completed by the Applicant Firm ( Firm ) on behalf of itself, its Predecessor Firm*, and all persons proposed for this insurance. Answer all questions completely. If space is insufficient to fully answer any question, complete the answer on Firm letterhead, sign and date that letter, and attach it to this Application. In addition, please attach: Copies of all letterhead(s) currently in use by the Firm. Copy of the Firm s expiring Declarations Page for Lawyers Professional Liability Insurance and all Policy Endorsements. Effective Date Requested : Full Legal Name of the Firm: Trade Name or D/B/A: Principal Address: (Principal office location MUST be in IL) City, State, Zip Code: County: Firm Phone Number: Firm Fax Number: Website: Date Firm Established : Contact Name: Contact Phone Number: Contact Address: INSTRUCTIONS FIRM INFORMATION Number of Non-Lawyer Personnel Position Number Position Number Paralegal Clerical Other (specify): Other (specify): Additional Firm Information 1. Does the Firm have any other office locations? If Yes, please complete the Additional Office Location Supplemental Application. 2. Does the Firm practice in states other than Illinois (including contingency fee referrals)? If Yes, please complete the Out of State Supplemental Application. 3. Does the Firm utilize co-counsel (CC), local counsel (LC), or refer cases (RC)? If Yes, please provide the information requested below: ISBAMIC SF NB APP PAGE 1 OF 6 LAWYERS PROFESSIONAL LIABILITY SF NB APPLICATION

2 Lawyer Firm Name City, State Relationship Confirmed Professional Liability is carried? Does the Firm outline and reduce to writing the relationship indicated above and outline the responsibilities of each Law Firm to the client? If Yes, does the client sign the letter confirming receipt and acceptance of the letter? Name of Predecessor Firm* Date Established Predecessor Firm* Information Date Dissolved Number of Owners, Officers, Partners, Associates, Employees, or Shareholders at Time of Dissolution Number of Owners, Officers, Partners, Associates, Employees, or Shareholders who Joined Successor Firm *Predecessor Firm means any Law Firm which prior to the effective date of the proposed Policy is dissolved and from which the Applicant Firm has retained at least 50% of the lawyers who were owners, officers, partners, associates, employees or shareholders. Lawyer Name Designation (see below) LAWYER INFORMATION Lawyer Roster (include yourself if you are a solo practitioner*) Date of Hire Date Admitted to IL Bar ISBA Number ARDC Number Average Number of Hours Worked per Week on Behalf of the Firm Date of Birth address Designations: O = Owner, Officer, or Shareholder; P = Partner of a Partnership; A = Associate or Employed Lawyer; S = Solo Practitioner; IC = Independent Contractor*; or OC = Of Counsel*. *Please complete the Of Counsel/Independent Contractor Supplemental Application. IN THE EVENT COVERAGE IS BOUND AND THE FIRM HIRES A NEW LAWYER DURING THE POLICY PERIOD, THE FIRM MUST NOTIFY THE COMPANY AND SUBMIT AN ADD A LAWYER SUPPLEMENTAL APPLICATION WITHIN THIRTY (30) DAYS OF JOINING THE FIRM FOR COVERAGE TO APPLY TO THE NEW LAWYER. *If you are an individual (solo practitioner), please identify the Lawyer who is designated to handle cases in the event of your absence or provide a detailed description on Firm letterhead, signed and dated, of your back-up plan in the event of your absence: Lawyer s Name Address (City, State, Zip) Telephone Number Lawyer s Professional Liability Carrier ISBAMIC SF NB APP PAGE 2 OF 6 LAWYERS PROFESSIONAL LIABILITY SF NB APPLICATION

3 FIRM INTERNAL PROCEDURES 1. Does the Firm have a procedure for evaluating New Clients/New Matters, such as, but not limited to, fit with Firm s Areas of Practice, conflict of interest check, the client s expectations, merits of the client s case and/or client s history of changing Lawyers? 2. Does the Firm have a Docket/Calendar Control System? If Yes, which of the following specific types of docket system(s) are used by the Firm? Docket Control System Docket Control System Computer Docket Software Master Calendar Individual Lawyer Diary (separate from Master Calendar) Tickler System Day-Timer Other (describe): 3. Which of the following Conflict of Interest methods are used by the Firm? N/A Conflict Check Method Conflict Check Method Computer Index File Client lists Conflict committee Memo/ to other Lawyers in the Firm Other (describe): 4. Does the Firm review client files every thirty (30) to sixty (60) days? 5. Does the Firm outline and reduce to writing its billing policy and procedures when agreeing to represent a new client? If Yes, what percentage of the time? % 6. Does the Firm use client engagement letters and/or contingency fee agreements which outline the scope of services to be provided when accepting all NEW MATTERS to the Firm? If Yes, what percentage of the time? % 7. In order to prevent being a victim of a fraudulent check scam, does the Firm confirm that all check, cashier s check and/ or money order funds have been paid by the payor s bank and the money actually deposited into the Firm s account (final settlement of check funds) prior to releasing any funds to another party? 8. How many lawsuits or arbitration proceedings has the Firm initiated to collect unpaid fees due and owing to the Firm in the past two (2) years that did not include family law? If more than three (3) fee dispute proceedings, please provide on Firm letterhead, signed and dated, the date of suit(s), nature of client representation, the total dollar amount in dispute, current status of the matter and if still a Firm client. 9. When evaluating whether a case should be sent for collection, is a complete review of the underlying work product completed to determine the likelihood of a counter-claim alleging malpractice? 10. Does the Firm wait until the applicable statute of limitation of a potential malpractice counter-claim has expired before filing a suit (or instituting arbitration) for fees? FIRM GROSS REVENUES 1. Please complete the following chart based upon all gross revenue generated by the Firm by dollar. Note: If the Firm is a start-up, please provide estimate for next 12 months only. Past 12 months Estimate for next 12 months $ $ 2. Does any one (1) client (including its subsidiaries and/or affiliates) of the Firm represent over 40% of the Firm s revenue? If Yes, please provide the following information for each client of the Firm who represent over 40% of the Firm s revenue: ISBAMIC SF NB APP PAGE 3 OF 6 LAWYERS PROFESSIONAL LIABILITY SF NB APPLICATION

4 Name of Client/State Client located % of Firm Revenue Industry of Client Number of Years as a Client of the Firm Legal Services Provided % % PRIOR CLAIMS EXPERIENCE AND/OR KNOWLEDGE OF LOSS 1. After inquiry, during the past five (5) years, has any professional liability Claim* been made against the Firm, any Predecessor Firm, or any present Lawyers of the Firm, or to your knowledge, any former Lawyer with the Firm or Predecessor Firm? If Yes, provide number. 2. After inquiry, is the Firm or any Lawyer in the Firm, aware of any potential Claim* including but not limited to an act, error, omission, fact, circumstance, request for a tolling agreement, a request for deposition, subpoena request for any file, ARDC complaint, situation, legal work, or any allegation of negligence that might result in any professional liability Claim* against the Firm, or any Predecessor Firm, or any past or present Lawyer in the Firm regardless whether such Claim* would be without merit? If Yes, provide number. If Yes, to questions 1 or 2 above, please complete a Claim Supplemental Application for each prior Claim* or potential Claim*. This Application must be accompanied by applicable currently valued Loss Runs for the Past Five (5) Years. 3. Have any of the Firm s Lawyers been the subject of any of the following disciplinary actions, investigations or proceeding by any court, bar association, administrative agency or regulatory body? Proceeding/Action Proceeding/Action Pending Investigation/Proceeding Censured Refused Admittance to Bar or Court Suspended Sanctioned or Fined Disbarred Reprimanded Other (specify): If Yes to any of the above, provide complete details of each on Firm letterhead, signed and dated, including copies of the complaint, current disposition and/or a copy of the final opinion or decision of the court, bar association, administrative agency or regulatory body. *Claim means a demand received for money or services, or the service of a suit or the initiation of an arbitration proceeding against the Applicant Firm that seeks damages arising out of an act, error or omission in rendering professional legal services including an act, error or omission of which the Applicant Firm, or anyone associated with the Applicant Firm is aware and which they know, or ought reasonably to have known, might give rise to a demand for money or services, or the service of suit or arbitration proceeding against them. IT IS UNDERSTOOD AND AGREED THAT THE COMPANY SHALL NOT BE LIABLE TO MAKE ANY PAYMENT FOR DAMAGES OR CLAIM EXPENSES IN CONNECTION WITH ANY CLAIM OR DISCIPLINARY ACTION, INVESTIGATION OR PROCEEDING MADE AGAINST ANY INSURED BASED UPON, ARISING OUT OF, DIRECTLY OR INDIRECTLY RESULTING FROM, IN CONSEQUENCE OF, OR IN ANY WAY INVOLVING ANY PROFESSIONAL LIABILITY CLAIM*, POTENTIAL CLAIM*, DISCIPLINARY ACTION, INVESTIGATION OR PROCEEDING, FACT, CIRCUMSTANCE, OR SITUATION SET FORTH, OR THAT SHOULD HAVE BEEN SET FORTH, IN CONNECTION WITH THE ABOVE QUESTIONS. PRIOR INSURANCE COVERAGE 1. Identify the Professional Liability Insurance Coverage carried by the Firm during the past five (5) years. Note: Please attach the Firm s current Declarations Page and all Endorsements of the policy. Effective Date Expiration Date Insurance Carrier Limits of Liability Deductible Annual Premium # of Insured Lawyers ISBAMIC SF NB APP PAGE 4 OF 6 LAWYERS PROFESSIONAL LIABILITY SF NB APPLICATION

5 2. Does the Firm s current Lawyers Professional Liability insurance policy have a retroactive date/prior acts date set forth either on the Declarations Page or in a prior acts exclusion endorsement? If Yes, what is the retroactive date? 3. Has the Firm, or any Predecessor Firm, purchased an Extended Reporting Period (ERP)/Tail Coverage under any current or past Lawyers Professional Liability insurance policy? If Yes, provide details on Firm letterhead, signed and dated, including reason for purchasing an ERP/Tail Coverage, length of ERP/Tail Coverage purchased, and date ERP/Tail Coverage commenced. 4. During the past five (5) years, has any insurance carrier canceled or refused to renew the Firm s Lawyers Professional Liability insurance for any reason other than carrier s withdrawal from the market? 5. During the past five (5) years, has any insurance carrier decreased the Firm s coverage at renewal? If Yes to either question 4 or 5 above, please provide a copy of the Non-Renewal Notice or Notice of Decrease in Coverage received by the Firm, including reason for such action. AREA OF PRACTICE Identify the Firm s Area of Practice based upon percentage of time (actual hours worked). Total must equal 100%. Note: If the Firm is a start-up, please provide estimate for next 12 months. Area of Practice % of Time past 12 months Area of Practice % of Time past 12 months Administrative % Employment Law Union % Admiralty/Maritime Litigation % Entertainment/Sports Law % Anti-Trust/Trade Regulation % Environmental Law % Appellate % Estate/Trust/Probate/Wills % Arbitration/Mediation % Family Law - Adoptions/Guardianships % Banking/Financial Institutions % Family Law Divorce % Bankruptcy/Foreclosure Court Appointed Trustee % Immigration & Naturalization % Bankruptcy/Foreclosure Creditor % Insurance Defense % Bankruptcy/Foreclosure Debtor % Intellectual Property Copyright/Trademark % BI/PI Defense % Intellectual Property Patent % BI/PI Plaintiff % Lobbying % Business & Commercial Litigation - Defense % Municipal Law no Bonds % Business & Commercial Litigation - Plaintiff % Oil/Gas/Mining % Business Formation and Alteration Formation & Dissolution % Oil/Gas/Mining Title % Business Formation and Alteration Mergers & Acquisitions % Real Estate - Commercial % Business Transactions International % Real Estate Residential % Business Transactions Private Corporation/Individuals % Real Estate Syndication/Development % Business Transactions Public Corporations % Securities Corporate/Municipal Bonds % Civil Rights/Discrimination % Securities Private Placements % Class Action/Mass Tort - Defense % Securities Public Offerings % Class Action/Mass Tort - Plaintiff % Social Security % Collections % Tax Commercial Ad Valorem % Commercial Law/Corporate * % Tax Residential Ad Valorem % Criminal/Traffic Law % Tax Prep/Tax Opinions - Corporate % Employment Law Benefits/ERISA % Tax Prep/Tax Opinions Personal % Employment Law Employee % Workers Compensation - Defense % Employment Law Employer % Workers Compensation - Plaintiff % TOTAL (from both columns) % *If over 15%, please provide a detailed description on Firm letterhead, signed and dated, of services provided. ISBAMIC SF NB APP PAGE 5 OF 6 LAWYERS PROFESSIONAL LIABILITY SF NB APPLICATION

6 REQUESTED LIMITS OF LIABILITY AND DEDUCTIBLE(S) NOTE: The Company pays the first $5,000 of CLAIM EXPENSES that the Company incurs as a result of a Claim that an Insured reports to the Company in writing in accordance with the Conditions Section of the Policy. Limits of Liability Each Claim/Annual Aggregate $250,000 / $500,000 $2,000,000 / $2,000,000 $0 Available to Solo Practitioners ONLY Deductible Each Claim $5,000 $250,000 / $750,000 $2,000,000 / $4,000,000 $10,000* $500,000 / $500,000 $3,000,000 / $3,000,000 $1,000 $15,000* $500,000 / $1,000,000 $4,000,000 / $4,000,000 $2,000 $20,000* $1,000,000 / $1,000,000 $5,000,000 / $5,000,000 $2,500 $25,000* $1,000,000 / $2,000,000 $5,000,000 / $10,000,000 $3,000 Other* $1,000,000 / $3,000,000 Other $ / $ $4,000 $ * If a Deductible of $10,000 or higher is selected, please provide Firm s Financial Statement or current Bank Statement evidencing Firm s ability to pay the requested Deductible level. REPRESENTATIONS AND WARRANTIES The Firm understands and agrees that the following representations and warranties are material and that the Company is relying on the truthfulness of these representations and warranties, which are made the basis of and a condition for the Company s acceptance of the risks covered by this insurance. The Firm further understands and agrees that if any of the following material representations and warranties are false, or if Firm fails to comply with any of the following representations and warranties at any time during the policy period, the Firm shall be deemed to have breached the insurance policy issued by the Company. The Firm hereby represents and warrants that the following are true and correct as of the inception date of the policy: a. The information contained in this Application, all material and information submitted to the Company in connection with this Application, and all material that is created and submitted to the Company by the Firm in connection with this insurance is a just, full and true exposition of all the facts and circumstances with regard to the risk to be insured. b. No Claim* has been made against the Firm or any person(s) proposed for this insurance nor has any person proposed for this insurance received a request for deposition in the past five (5) years and no disciplinary action, investigation or proceeding have been filed against any Lawyer proposed for this insurance other than as disclosed in the Application and/or loss runs submitted to the Company. c. The Firm or any Lawyer in the Firm is not aware of any potential Claim* including but not limited to an act, error, omission, fact, circumstance, tolling agreement, request for deposition, a subpoena for any file, disciplinary action, investigation or proceeding, situation, legal work or any allegation of negligence that might result in any professional liability Claim* against the Firm, or any Predecessor Firm, or any past or present Lawyer in the Firm regardless whether such Claim* would be without merit other than as disclosed in the Application. ACKNOWLEDGEMENTS The undersigned declares that to the best of his or her knowledge, the statements set forth herein are true and accurate and that reasonable efforts have been made to obtain sufficient information from all persons proposed for this insurance to facilitate the proper and accurate completion of this Application. The signing of the Application does not bind the Company to complete the insurance, but it is agreed that this Application, all material and information submitted to the Company in connection with this Application, and all material that is created by the Firm and submitted to the Company in connection with this insurance are the representations of the Firm and are material and shall be the basis of the contract should a policy be issued. The undersigned further agrees that if any significant adverse change in the condition of the Firm is discovered between the date of completion of this Application and the date that coverage was bound with the Company, and such change renders this Application inaccurate or incomplete, notice of such change will be reported in writing to the Company immediately. This Application shall be considered attached to and part of the Policy. Any material submitted with the Application shall be maintained on file with the Company and shall be deemed to be attached hereto as if physically attached. SIGNATURE Signature of Owner, Officer, Partner, Shareholder, or Member Name: Title: Address: SIGNATURE DATE ISBAMIC SF NB APP PAGE 6 OF 6 LAWYERS PROFESSIONAL LIABILITY SF NB APPLICATION